Congress Passes Bill to Avert Cuts, Extend Cap Exceptions Process

Yesterday,
the House and Senate passed legislation to bring the nation back from the
"fiscal cliff" that includes 5 important provisions for physical
therapists. The bill has been sent to President Obama for his signature.

The American
Taxpayer Relief Act of 2012 (HR 8) freezes the Medicare conversion factor for
2013 at the 2012 level, averting a 26.5% cut to physical therapists and other
providers under the physician fee schedule, and continues the 1.0 GPCI work
value floor through 2013. The legislation also extends the current 2-tier
therapy cap exceptions process ($1,900 automatic KX modifier process, $3,700
manual medical review, and application of the therapy cap to hospital outpatient
department) for 1 year. Additionally, in a provision that APTA has called "unjustified,
capricious, and poor public policy," the bill applies the multiple procedure payment reduction (MPPR) to therapy services at 50%, up from 20%
for office settings and 25% for facility settings, beginning April 1. APTA estimates
the application of a 50% MPPR policy will reduce payments by approximately 6-7%.
This reduction will be partially offset by a 4% increase that resulted from the
Centers for Medicare and Medicaid Services' (CMS) use of new survey data of
practice expenses conducted by APTA. Coupled together, APTA expects the net
overall decrease for outpatient therapy services to be between 2%-3% beginning
April 1. APTA will update the MPPR calculator on its website in the coming
days. APTA will advocate to stop
the implementation of the MPPR provision.

HR 8 also
postpones sequestration cuts until March 1. Under these cuts Medicare providers
would see a 2% reduction in payment. The National Institutes of Health and
other federal agencies would see reductions of 7%-8%.

Several other policies of
importance to physical therapists went into effect January 1. Under the functional limitations reporting requirement for Medicare Part B
services, physical therapists must include nonpayable G-codes and
modifiers on claim forms to capture data on the beneficiary's functional
limitations at the outset of the therapy episode, at a minimum of every 10th
visit, and at discharge. To
ensure a smooth transition, the Centers for Medicare and Medicaid Services has
set forth a testing period from January 1 until July 1. After July 1 claims
submitted without the appropriate G-codes and modifiers will be returned
unpaid.

In addition,
physical therapists who successfully participate in the Physician Quality Reporting System in 2013 can obtain a 0.5% bonus payment in 2013 and 2014 and will avoid
penalties of 1.5% in 2015.

APTA will continue to provide updates and post resources to
help members comply with 2013 Medicare policies.

Comments

Hello, I have read conflicting information about the manual medical review component. I have heard that no second tier exist. What is being used to base this information? Is this something from CMS or in the legislation? Thank you in advance.

Posted by LW
on 1/2/2013 3:43 PM

What is the source document citing the 4% increase in rates resulting from CMS use of new survey data of practice expenses conducted by APTA? This is mentioned in your article. Thank you.

Posted by Juliet Wooten
on 1/2/2013 6:51 PM

Hello. does MPPR aplies to any consequtive procedures or the same procedure which is billed as multiple units? anothwr way therapeutic exercises 2 units at the same will ended with first unit paid 100% and second only 50%. is the same apply to 1 unit ther.eexercises and 1 unit manual therapy? with exercise unit will be paid 100% and manual therapy will be paid 50% only or manual therapy unit will be paid 100% ? thank you for your help.

Posted by robert dragan
on 1/2/2013 10:10 PM

hi does the G codes only pertain to medicare or the supplements of medicare as well. thank you,

Posted by Gaynell Anderson -> =FVb>
on 1/3/2013 9:13 AM

Regarding the MPPR - I don't understand how the APTA calculates that this would only be at 2-3% overall reduction in outpatient reimbursement, even if there is a 4% increase. MPPR - would reimburse 100% for the first CPT code (that has the highest reimbursement) but then only 80% reimbursement for the rest of their treatment??? so if the pt receives 2 units of Manual Therapy (97140) and 2 units of There ex (97110) - we would be reimbursed fully for one unit and then the other 3 units would be reduced by 20% - so basically the Physicians Fee Schedule is taking a hit! Am I correctly understanding this ????

Posted by Scottie Bull
on 1/3/2013 9:52 AM

To Scottie Bull: Sorry Sir, not 20% but 50%!

Posted by Bob
on 1/3/2013 5:02 PM

Physical Therapists are a vital profession in America. The impacts of 'The American Taxpayer Relief Act of 2012(HR 8) and sequestration should wisely factor in any detrimental effects on services for individuals with disabilities, many of whom are senior citizens, school-age children, insufficiently insured/uninsured families, as well as, the under-employed adult labor force. The federal government, Congress, federal/state/local agencies and key stakeholders should think of the pervasive and long-term affects of how a limited or nonexistent physical therapy services would alter America's citizens/taxpayers/voters' daily life.

Posted by Brenda L. Cosse'
on 1/4/2013 6:02 AM

Does anyone know if critical
access hospitals are still exempt
from the therapy cap?

Posted by JS
on 1/4/2013 4:35 PM

LW: Under HR 8, the entire therapy cap exceptions process, including manual medical review at $3,700, was renewed. The legislation amended the provisions from the 2012 extension by substituting December 31, 2013 as the new date of expiration.

Posted by News Now Staff
on 1/4/2013 6:25 PM

Juliet Wooten: CMS published the final 2013 Medicare physician fee schedule rule in the November 16, 2012 Federal Register. This rule includes an impact table (Table 134) that shows the impact of the changes to relative value units on the rule for each specialty. In this table, CMS indicates that there is a positive 4% impact on practice expense for the physical therapy specialty. The link to the final physician fee schedule rule is includes below. This is a large document so when you open the document, search for "Table 134." https://www.federalregister.gov/articles/2012/11/16

Posted by News Now Staff
on 1/4/2013 6:27 PM

Robert Dragan: The MPPR will allow payment at 100% for one unit of service. If two units (30 minutes) of therapeutic exercise (97110) is billed, then one unit (15 minutes) would be paid at 100% and the second unit of 97110 would be reduced in accordance with the MPPR policy. If one unit of therapeutic exercise and one unit of manual therapy are billed, 97110 would be paid at 100% and 97140 would have the MPPR reduction applied to it. APTA has a document on our website that includes further description of how the MPPR policy works.

Posted by News Now Staff
on 1/4/2013 6:28 PM

Gaynell Anderson: The G codes for reporting functional information on the claim form apply for Medicare fee for service only at this time.

Posted by News Now Staff
on 1/4/2013 6:29 PM

Scottie Bull: Since 2011, physical therapists have already received a 20-25% (20% for private practices, 25% to facilities) MPPR on outpatient therapy services delivered on the same day. This means that the code with the highest practice expense value that day will be reimbursed at 100% and the second and subsequent codes will be reduced by 20-25% of the practice expense value when multiple therapy services are billed on the same date by the same practitioner or facility under the same NPI, regardless of whether those therapy services are furnished in separate sessionsThe work and malpractice components of the therapy service payment would not be reduced. APTA estimates the application of a 50% MPPR policy will reduce payments by approximately 6-7% in aggregate for outpatient therapy services. This reduction will be partially offset by a 4% increase in practice expense that resulted from CMS’s use of new survey data of practice expenses conducted by APTA. The impact of the MPPR reduction on individual practices and facilities will vary depending on the CPT codes billed and the typical duration of the therapy sessions. To determine the impact on your practice, refer to APTA's MPPR calculator, which can be used to determine payment rates for 2012 and 2013. A link to that calculator and other info can be found here: http://www.apta.org/Payment/Medicare/2013/Changes/

Posted by News Now Staff
on 1/4/2013 6:31 PM

Critical access hospitals were exempt from the outpatient therapy cap in 2012. Does this still hold true for 2013?

Posted by Dr. Steve Volpe
on 1/7/2013 9:36 PM

This is the only information I can find in regards to CAH. My understanding of "Section 603 - Extension Related to Payments for Medicare Outpatient Therapy Services" is that CAH are no longer exempt from the cap. But I would appreciate any more information/feedback from the APTA or its members.

Posted by Rachel Wyman Dawson
on 1/8/2013 3:15 PM

Is the MPPR reducation effecting everyone across the USA. According to the calculator on the APTA website it is just a few of the states. Looking for information on New York State.

Posted by LISA
on 1/9/2013 5:42 PM

Does anyone have an answer as to whether the new G codes and C codes are required for patients that are continuing dates of service from 2012 onto 2013? Or is Medicare requiring application of the G codes/C codes only for new patients seen in 2013?

Posted by Yvette
on 1/16/2013 1:22 AM

I would also like to know if CAH are still exempt from the therapy cap.